Provider Demographics
NPI:1164642682
Name:SOUTHERN OREGON NEUROLOGY PC
Entity type:Organization
Organization Name:SOUTHERN OREGON NEUROLOGY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BOOKKEEPER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ERIKA
Authorized Official - Middle Name:
Authorized Official - Last Name:HUBER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-772-1119
Mailing Address - Street 1:897 ROYAL AVE
Mailing Address - Street 2:STE B
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-6121
Mailing Address - Country:US
Mailing Address - Phone:541-779-4991
Mailing Address - Fax:541-772-2910
Practice Address - Street 1:897 ROYAL AVE
Practice Address - Street 2:STE B
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-6121
Practice Address - Country:US
Practice Address - Phone:541-779-4991
Practice Address - Fax:541-772-2910
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-26
Last Update Date:2007-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR182618Medicaid
ORR0000WCGMGMedicare PIN
ORR109338Medicare PIN